The document discusses how value-based care requires new approaches to engage patients and improve outcomes while lowering costs. It argues that e-health tools can help by enabling better care coordination, remote patient monitoring, social support for patients, and customized care programs. These e-health disciplines are important for engaging patients in their care in new ways to support value-based models.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
This infographic speaks to the challenges Emergency Departments face in caring and following up with the growing population of patients they see, and demonstrates how some EDs are seeing measurable improvements in care, patient satisfaction and efficiency.
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
The document summarizes a presentation by Paul Grundy on extracting value from the patient centered medical home model. It discusses:
1) How the patient centered medical home model creates partnerships across the healthcare system to drive primary care redesign, offer population health management, and move away from an episodic, fee-for-service model.
2) Studies that show improvements in costs, quality, access, and utilization from implementing the patient centered medical home model, including reduced hospital and ER use.
3) How payment models are shifting towards value-based purchasing tied to quality, utilization, and patient satisfaction outcomes rather than volume of services.
Patients and their loved ones often hold critical knowledge that informs diagnosis. This toolkit from the Institute of Medicine offers patients, families and clinicians guidance on how they can collaborate to improve diagnosis.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
This document provides a summary of evidence on the impact of patient-centered medical homes (PCMHs) and primary care innovations on cost and quality from 2013-2014. It finds that PCMH interventions are associated with modest improvements in quality of care and reductions in utilization and costs. It also discusses challenges in evaluating PCMHs and outlines opportunities to further integrate primary care with other specialties and engage consumers. The future of the PCMH relies on continued financial support, training interprofessional teams, harnessing technology, and partnering with patients and communities.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
This infographic speaks to the challenges Emergency Departments face in caring and following up with the growing population of patients they see, and demonstrates how some EDs are seeing measurable improvements in care, patient satisfaction and efficiency.
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
The document summarizes a presentation by Paul Grundy on extracting value from the patient centered medical home model. It discusses:
1) How the patient centered medical home model creates partnerships across the healthcare system to drive primary care redesign, offer population health management, and move away from an episodic, fee-for-service model.
2) Studies that show improvements in costs, quality, access, and utilization from implementing the patient centered medical home model, including reduced hospital and ER use.
3) How payment models are shifting towards value-based purchasing tied to quality, utilization, and patient satisfaction outcomes rather than volume of services.
Patients and their loved ones often hold critical knowledge that informs diagnosis. This toolkit from the Institute of Medicine offers patients, families and clinicians guidance on how they can collaborate to improve diagnosis.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
This document provides a summary of evidence on the impact of patient-centered medical homes (PCMHs) and primary care innovations on cost and quality from 2013-2014. It finds that PCMH interventions are associated with modest improvements in quality of care and reductions in utilization and costs. It also discusses challenges in evaluating PCMHs and outlines opportunities to further integrate primary care with other specialties and engage consumers. The future of the PCMH relies on continued financial support, training interprofessional teams, harnessing technology, and partnering with patients and communities.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
This document discusses 5 elements of a successful patient engagement strategy:
1. Define your organization's vision for patient engagement.
2. Create a culture of engagement within the practice.
3. Employ the right technology and services like patient portals.
4. Empower patients to become collaborators in their care.
5. Continuously evaluate progress and be ready to adapt the strategy.
True patient engagement involves patients managing their own health, a practice culture that prioritizes engagement, and collaboration between patients and providers.
This document discusses outcomes-based contracts between pharmaceutical companies and payers. It provides background on rising healthcare costs, describes the benefits of outcomes-based contracts for stakeholders, and gives examples of existing contracts linked to outcomes like reduced hospitalizations or reaching clinical targets. The document also outlines challenges, keys to success, and potential future applications in areas like specialty medications.
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Revie...CHC Connecticut
Dr. Nwando Olayiwola, Associate Director, Center for Excellence in Primary Care, Assistant Professor, University of California, San Francisco addresses the 2014 Weitzman Symposium on The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Review of Evidence
YourCare is a program launched by CoreSource to help employees better manage their health and chronic conditions. A study found that employees in the YourCare program had improved preventative care, fewer hospital admissions, and as a result, lower overall healthcare costs for employers. Specifically, YourCare participants visited doctors 6% more and filled 14% more prescriptions. They also had fewer care gaps and hospital admissions that were 12% lower. After risk-adjusting for differences in participants' health risks, the total costs were 6% lower for the YourCare group. Offering YourCare can help employers successfully manage high-risk employees and lower costs.
The document discusses creating a value-based healthcare system focused on patient outcomes and costs. It recommends organizing multidisciplinary teams around patient conditions, measuring outcomes and costs by condition, and developing bundled payments to compensate providers for treating a condition over the full cycle of care. The document also provides an example of Martini Klinik in Germany, which achieves better prostate cancer outcomes than average hospitals through dedicated teams, extensive outcomes tracking, and peer comparison.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
To lower health costs, physician networks and medical homes must employ a closed loop population management program that focus on patient SOH stratification, chronic disease management, care coordination and incentive management. This approach will enable them to consistently reduce ER and inpatient admissions, which are the greatest expenditures in health care today.
This presentation explains the concept of the patient-centered medical home (PCMH), its function and its intended effects. A brief overview of the history of PCMH is also provided, as well as a discussion of its operational characteristics, its principles and outcomes, and what is expected in the future for the PCMH model.
The Kaiser Permanente Homeless Navigator Pilot Program in Woodland Hills, California connects homeless patients with community resources to help them find housing and other services, placing over 576 homeless patients in shelters and programs since 2012. The program uses a team approach involving medical, social work, and community staff. It has been successful in transforming lives and ending homelessness for many patients.
Patient-centered medical home initiatives in several states have shown promising results in improving access to care, quality, and cost control for Medicaid patients. Oklahoma saw a $29 per patient annual reduction in Medicaid costs from 2008-2010 alongside increased use of preventive care. Colorado expanded Medicaid access from 20% to 96% of pediatricians at lower costs. Vermont saw 21-22% decreases in inpatient care use and costs from 2008-2010 alongside 31-36% drops in ER use and related costs. Washington state's acute care spending was 18% below average with 35% fewer inpatient stays per beneficiary. Overall, these initiatives demonstrate that the patient-centered medical home model can positively impact Medicaid programs.
Patient engagement is evolving to include a composite of practices that impact patient behaviors and health. Contemporary models of patient engagement include the HIMSS 5 phases of patient engagement and the Regional Primary Care Coalition's 6 dimensions of patient engagement. Meaningful Use Phase 3 identifies key priorities around patient access to health records and secure messaging. Barriers to patient engagement include defining engagement and integrating diverse engagement tools and technologies.
This document discusses approaches to personalizing quality measurement in healthcare. It outlines three fundamental approaches:
1) Integrating patient-reported outcome and experience measures (PROMs and PREMs) into clinical workflow to better capture patients' health status and perspectives.
2) Encouraging patients' and clinicians' joint generation of medical records, such as through the OpenNotes project, to improve patient engagement, communication, and safety reporting.
3) Measuring decision quality through shared decision making between clinicians and patients to respect patient autonomy and better account for individual risk-benefit preferences in medical decisions. The document argues for rapidly adopting these personalized approaches and incentivizing their use through payment reform.
Health Rosetta Case Study - City of Kirkland, WashingtonDave Chase
City of Kirkland, WA is a suburb of Seattle that was, like municipalities, struggling with healthcare costs and feared the coming Cadillac Tax. Their "moonshot" goal was to improve health benefits while eliminating healthcare cost inflation
This study examined how characteristics of medical group practices influence rates of inappropriate emergency department visits and avoidable hospital admissions among Medicare patients. The researchers found that practices owned by physicians and those using electronic health records had lower rates of non-emergent ED visits and emergent but primary care treatable visits. Larger practices and those with more non-physician providers per doctor had higher rates of avoidable hospital admissions. The findings suggest that care coordination declines as practices grow in size and complexity.
The document discusses several topics:
1. A new set of criteria has been developed by NCQA and PCPCC to recognize physician practices as patient-centered medical homes based on 7 principles.
2. Matria has partnered with Microsoft to support HealthVault, a new health platform that allows users to store and access personal health information online.
3. A case study describes how Matria client BD integrated disability management with disease management, increasing participation in health programs from 23% to 48%.
From Patients to ePatients Driving a new paradigm for online clinical collabo...ddbennett
CareTech eHealth Innovation Series
From Patients to ePatients Driving a new paradigm for online clinical collaboration and health management
David Bennett, SVP, Interactive Solutions
StayWell Custom Communications
Anthony Chipelo, Director, Portal Strategies
CareTech Solutions
This document contains a summary of several articles from the September/October 2012 issue of Partners magazine. The cover story discusses how Virginia Mason Medical Center adapted the Toyota production method to healthcare to reduce waste and standardize care protocols. A special report profiles how Geisinger Health Care, Atrius Health, and Advocate Health Care are leading the way in coordinated care across the care continuum as accountable care organizations proliferate. The back page focuses on the complex rules and methodology surrounding the Medicare Readmissions Reduction Program.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
This document discusses 5 elements of a successful patient engagement strategy:
1. Define your organization's vision for patient engagement.
2. Create a culture of engagement within the practice.
3. Employ the right technology and services like patient portals.
4. Empower patients to become collaborators in their care.
5. Continuously evaluate progress and be ready to adapt the strategy.
True patient engagement involves patients managing their own health, a practice culture that prioritizes engagement, and collaboration between patients and providers.
This document discusses outcomes-based contracts between pharmaceutical companies and payers. It provides background on rising healthcare costs, describes the benefits of outcomes-based contracts for stakeholders, and gives examples of existing contracts linked to outcomes like reduced hospitalizations or reaching clinical targets. The document also outlines challenges, keys to success, and potential future applications in areas like specialty medications.
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Revie...CHC Connecticut
Dr. Nwando Olayiwola, Associate Director, Center for Excellence in Primary Care, Assistant Professor, University of California, San Francisco addresses the 2014 Weitzman Symposium on The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Review of Evidence
YourCare is a program launched by CoreSource to help employees better manage their health and chronic conditions. A study found that employees in the YourCare program had improved preventative care, fewer hospital admissions, and as a result, lower overall healthcare costs for employers. Specifically, YourCare participants visited doctors 6% more and filled 14% more prescriptions. They also had fewer care gaps and hospital admissions that were 12% lower. After risk-adjusting for differences in participants' health risks, the total costs were 6% lower for the YourCare group. Offering YourCare can help employers successfully manage high-risk employees and lower costs.
The document discusses creating a value-based healthcare system focused on patient outcomes and costs. It recommends organizing multidisciplinary teams around patient conditions, measuring outcomes and costs by condition, and developing bundled payments to compensate providers for treating a condition over the full cycle of care. The document also provides an example of Martini Klinik in Germany, which achieves better prostate cancer outcomes than average hospitals through dedicated teams, extensive outcomes tracking, and peer comparison.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
To lower health costs, physician networks and medical homes must employ a closed loop population management program that focus on patient SOH stratification, chronic disease management, care coordination and incentive management. This approach will enable them to consistently reduce ER and inpatient admissions, which are the greatest expenditures in health care today.
This presentation explains the concept of the patient-centered medical home (PCMH), its function and its intended effects. A brief overview of the history of PCMH is also provided, as well as a discussion of its operational characteristics, its principles and outcomes, and what is expected in the future for the PCMH model.
The Kaiser Permanente Homeless Navigator Pilot Program in Woodland Hills, California connects homeless patients with community resources to help them find housing and other services, placing over 576 homeless patients in shelters and programs since 2012. The program uses a team approach involving medical, social work, and community staff. It has been successful in transforming lives and ending homelessness for many patients.
Patient-centered medical home initiatives in several states have shown promising results in improving access to care, quality, and cost control for Medicaid patients. Oklahoma saw a $29 per patient annual reduction in Medicaid costs from 2008-2010 alongside increased use of preventive care. Colorado expanded Medicaid access from 20% to 96% of pediatricians at lower costs. Vermont saw 21-22% decreases in inpatient care use and costs from 2008-2010 alongside 31-36% drops in ER use and related costs. Washington state's acute care spending was 18% below average with 35% fewer inpatient stays per beneficiary. Overall, these initiatives demonstrate that the patient-centered medical home model can positively impact Medicaid programs.
Patient engagement is evolving to include a composite of practices that impact patient behaviors and health. Contemporary models of patient engagement include the HIMSS 5 phases of patient engagement and the Regional Primary Care Coalition's 6 dimensions of patient engagement. Meaningful Use Phase 3 identifies key priorities around patient access to health records and secure messaging. Barriers to patient engagement include defining engagement and integrating diverse engagement tools and technologies.
This document discusses approaches to personalizing quality measurement in healthcare. It outlines three fundamental approaches:
1) Integrating patient-reported outcome and experience measures (PROMs and PREMs) into clinical workflow to better capture patients' health status and perspectives.
2) Encouraging patients' and clinicians' joint generation of medical records, such as through the OpenNotes project, to improve patient engagement, communication, and safety reporting.
3) Measuring decision quality through shared decision making between clinicians and patients to respect patient autonomy and better account for individual risk-benefit preferences in medical decisions. The document argues for rapidly adopting these personalized approaches and incentivizing their use through payment reform.
Health Rosetta Case Study - City of Kirkland, WashingtonDave Chase
City of Kirkland, WA is a suburb of Seattle that was, like municipalities, struggling with healthcare costs and feared the coming Cadillac Tax. Their "moonshot" goal was to improve health benefits while eliminating healthcare cost inflation
This study examined how characteristics of medical group practices influence rates of inappropriate emergency department visits and avoidable hospital admissions among Medicare patients. The researchers found that practices owned by physicians and those using electronic health records had lower rates of non-emergent ED visits and emergent but primary care treatable visits. Larger practices and those with more non-physician providers per doctor had higher rates of avoidable hospital admissions. The findings suggest that care coordination declines as practices grow in size and complexity.
The document discusses several topics:
1. A new set of criteria has been developed by NCQA and PCPCC to recognize physician practices as patient-centered medical homes based on 7 principles.
2. Matria has partnered with Microsoft to support HealthVault, a new health platform that allows users to store and access personal health information online.
3. A case study describes how Matria client BD integrated disability management with disease management, increasing participation in health programs from 23% to 48%.
From Patients to ePatients Driving a new paradigm for online clinical collabo...ddbennett
CareTech eHealth Innovation Series
From Patients to ePatients Driving a new paradigm for online clinical collaboration and health management
David Bennett, SVP, Interactive Solutions
StayWell Custom Communications
Anthony Chipelo, Director, Portal Strategies
CareTech Solutions
This document contains a summary of several articles from the September/October 2012 issue of Partners magazine. The cover story discusses how Virginia Mason Medical Center adapted the Toyota production method to healthcare to reduce waste and standardize care protocols. A special report profiles how Geisinger Health Care, Atrius Health, and Advocate Health Care are leading the way in coordinated care across the care continuum as accountable care organizations proliferate. The back page focuses on the complex rules and methodology surrounding the Medicare Readmissions Reduction Program.
The document discusses the challenges facing U.S. hospitals as the healthcare system shifts from fee-for-service to value-based payments. This shift requires hospitals to change their business model from focusing on individual interventions to providing integrated, population-based care. A survey found that hospital executives recognize the need to substantially change their business model to survive financially under the new system. The experiences of integrated healthcare systems that have adopted this new model show improved health outcomes and cost savings. However, making the transition will be difficult and involves cultural as well as operational changes.
This document discusses pay for performance (P4P) and its implications for healthcare organizations. It explains that P4P aims to improve quality by directly incentivizing superior care delivery. The document outlines drivers of P4P like rising healthcare costs and quality issues. It also reviews current P4P programs and discusses strategies organizations can take to prepare, like integrating performance data and contracting approaches that reward quality and efficiency.
The document discusses improving health in communities by aligning incentives to make health profitable. It notes the US healthcare system is strained by chronic conditions exacerbated by an aging population. Experts discuss changing models and behaviors, and how to ensure healthcare reform improves overall community health rather than just preserving existing imbalances. Key ideas discussed include making health states profitable through business models, improving data sharing and transparency, and driving behavioral changes through community efforts.
Painsolver is a clinical decision support tool designed to improve healthcare outcomes for low back pain. It addresses limitations in how patient care is currently managed by providing evidence-based guidance, integrating recommendations into workflows, and promoting shared decision making between providers and patients. The tool aims to help organizations and providers succeed under emerging pay-for-performance models by enhancing outcomes and reducing costs over a patient's lifetime. Vertelogics believes Painsolver can help providers and organizations not just survive but thrive as the healthcare system shifts its focus to outcomes-based reimbursement.
NCQA_Future Vision for Medicare Value-Based Payments FinalTony Fanelli
This document discusses principles for achieving an optimal future state of quality measurement to support performance-based clinician payment under MACRA. It outlines five principles: 1) Every Medicare enrollee needs a dedicated and well-organized primary care team; 2) Measurement must be specified appropriately for each different unit of accountability; 3) Measurement should support rapid improvement and clinical decision making; 4) A core set of measures will let all stakeholders make comparisons across programs; 5) Quality measure results should be easy for consumers and payers to get and use. The document emphasizes the importance of coordinated, team-based primary care and having measures tailored to different payment and delivery models.
Accountable Care Organizations and Physician Joint Ventures .docxAMMY30
Accountable Care Organizations and Physician Joint Ventures
Jeffrey P. Harrison
Chapter 9
“I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient.”
—from The Hippocratic Oath (modern version)
Copyright 2016 Foundation of the American College of Healthcare Executives. Not for sale.
1
Learning Objectives
Demonstrate an understanding of the interparty relationships associated with healthcare joint ventures and accountable care organizations.
Understand some of the dynamics and controversies surrounding the concept of accountable care organizations as an alternative approach to the current marketplace.
Demonstrate a basic understanding of the patient-centered medical home with attention to how it supports network-based delivery systems.
Master the concept of physician–hospital alignment and health system integration including consumer, provider, and regulatory developments.
Assess the emerging role of medical groups and hospital-owned group practices across the continuum of healthcare services.
Copyright 2016 Foundation of the American College of Healthcare Executives. Not for sale.
2
Key Terms and Concepts
Accountable care organization (ACO)
Clinical integration
Equity-based joint venture
Hospitalist model
Integrated physician model
Medical foundation
Patient-centered medical home (PCMH)
Copyright 2016 Foundation of the American College of Healthcare Executives. Not for sale.
3
Introduction
A positive relationship between hospitals and physicians is important to the success of the US healthcare system, because hospitals and physicians can be both collaborators and competitors.
Many hospitals and healthcare systems have moved to various models of physician integration through which hospitals hope to capture market share and physicians seek financial security.
After the Affordable Care Act (ACA) was passed in 2010, physician–hospital alignment became driven by another factor: cost control and quality outcomes in the accountable care era (Reiboldt 2013).
Physicians work in a wide range of settings and serve in leadership positions that have significant responsibility for quality of care.
Copyright 2016 Foundation of the American College of Healthcare Executives. Not for sale.
4
Clinical Integration
What Is It?
Coordination of patient care between hospitals and physicians across the healthcare continuum— e.g., an accountable care organization (ACO).
Provides an opportunity to coordinate services through centralized scheduling, electronic health records, clinical pathways, management of chronic diseases, and innovative quality improvement programs.
Clinical integration is necessary to delivering high-quality, affordable care in the current environment (Jacquin 2014).
Clinical.
EDM ForumEDM Forum CommunityeGEMs (Generating Evidence & M.docxgreg1eden90113
EDM Forum
EDM Forum Community
eGEMs (Generating Evidence & Methods to
improve patient outcomes) Publish
4-20-2017
Reducing Healthcare Costs Through Patient
Targeting: Risk Adjustment Modeling to Predict
Patients Remaining High-Cost
Jonathan A. Wrathall
Intermountain Healthcare, [email protected]
Tom Belnap
Intermountain Healthcare, [email protected]
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Recommended Citation
Wrathall, Jonathan A. and Belnap, Tom (2017) "Reducing Healthcare Costs Through Patient Targeting: Risk Adjustment Modeling to
Predict Patients Remaining High-Cost," eGEMs (Generating Evidence & Methods to improve patient outcomes): Vol. 5: Iss. 2, Article 4.
DOI: https://doi.org/10.13063/2327-9214.1279
Available at: http://repository.edm-forum.org/egems/vol5/iss2/4
Reducing Healthcare Costs Through Patient Targeting: Risk Adjustment
Modeling to Predict Patients Remaining High-Cost
Abstract
Context: The transition to population health management has changed the healthcare landscape to identify
high risk, high cost patients. Various measures of patient risk have attempted to identify likely candidates for
care management programs. Pre-screening patients for outreach has often required several years of data.
Intermountain Healthcare relied on cost-ranking algorithms which had limited predictive ability. A new risk-
adjusted algorithm shows improvements in predicting patients’ future cost status to facilitate identifying
patient eligibility for care management.
Case Description: A retrospective cohort study design was used to evaluate high-cost patient status for two
of the next three years. Modeling was developed using logistic regression and tested against other decision tree
methods. Key variables included those readily available in electronic health records supplemented by
additional clinical data and estimates of socio-economic status.
Findings: The risk-adjusted modeling correctly identified 79.0% of patients ranking among the top 15% of
costs in one of the next three years. In addition, it correctly estimated 48.1% of the patients in the top 15% cost
group in two of the next three years. This method identified patients with higher medical costs and more
comorbid conditions than previous cost-ranking methods.
Major Themes: This approach improves the predictive accuracy of identifying high cost patients in the future
.
The document discusses various topics related to physical therapy (PT) practice. It notes that in 2014, PTs can avoid PQRS penalties by reporting 3 quality measures for 50% of patients, and the number of measures required to receive bonuses will increase from 3 to 9. It also eliminates reporting via measures groups through claims. The document discusses focusing on developing quality measures for PT, payment models that promote value, and public policy initiatives to advance the role of PT in areas like disease management. It also discusses improving access, eliminating self-referral profits, and ensuring an adequate PT workforce.
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
1. The document discusses issues with the current healthcare system including lack of coordination between institutions, dehumanization of care, and rising costs.
2. It introduces case management as a promising solution, defined as a method that aims for continuity of services and quality clinical outcomes through efficient management of available resources for specific clientele.
3. Case management relies on thorough knowledge of client needs, estimating patient stay lengths, and planning coordinated treatment processes to improve care quality while controlling costs.
Running Head: PHYSICIAN
PHYSICIAN 7
Health Care Provider: Physician
Marcia Harrison
Strayer University
Professor Hwangi Lu
July 28, 2019
Physician
Introduction
A healthcare system should be well organized and should consist of trained personnel who mainly work with a company or an organization. Physicians, nurses, doctors, pharmacists are some of the examples of health care providers. This is a system that provides professional services to patients that are in high need of treatment as inpatients who are treated generally as outpatients. I decided to select physicians as health care providers and also as medical practitioners since they are always in demand in the medical field, day after another. This is a professional medical practitioner or by simple terms, a doctor who has completed highly advanced training in providing a range of mostly non-surgical health care to patients. A physician should have adverse knowledge in a medical specialty. The main concern is to maintain, restore, and promote health via the study, treatment, and diagnosis of a disease of patients to ensure their wellbeing.
Direct Impact of a Physician
Most companies direct the efforts of their marketing towards physicians to the consumers who are their patients; the shots are put in the physicians through the sale of drugs and also by advertising in most of the medical journals. Most of the largest chunk is put in place towards the detailing of marketing expenditure through advertisement. Some direct adverse impacts towards physicians are the misleading claims, indications that are unapproved and also overstated clinical issues. It has led to patients heading to physicians on a matter regarding well preventive healthcare (Machanda, 2005) since most drug adverts have left patients having an excellent aid of discussions with their physicians regarding treatment through which only safe drugs are allowed.
Physicians and their patients have put into caution through dealing with advertisement of drugs as they use forums which are web-based for their advertisements as they have a literature of promotion on their background which makes them be excluded in the blacklist by companies and by the agency of the regulatory. The detailing through rifeness over the drugs life has been adopted as an explanation of better effectiveness and efficiency of physician firms and improvement of patient’s health. As an industry, it plays a vital role in the economy of the world and also promoting the welfare of the consumers who are the citizens of the nation towards the healthcare industry.
Strategy for a Physician
Data integrity is a critical strategy that physicians ought to adopt for the statistical review and pattern utilization as a technological step in the medical field, this will help in recoding the patients ...
Submission Id ab299d7c-b547-4cf3-958a-07922ca71f2765 SIM.docxdeanmtaylor1545
Submission Id: ab299d7c-b547-4cf3-958a-07922ca71f27
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Patience Nehikhare
healthcaredeliverysystemchanges.docx
Summary
1175 Words
Running Head: HEALTHCARE DELIVERY SYSTEM
THE U.S. HEALTHCARE DELIVERY SYSTEM 2
Healthcare Delivery System
Patience Nehikhare
Grand Canyon University
December 22, 2019
The U.S. Healthcare Delivery System
There is a rapid change within the healthcare system in the United States. The
changes that have occurred were made for the purpose of improving quality,
rewarding value and not volume, as well as integrating and coordinating the care
(Seshamani & Sen, 2018). As such, this paper will seek to put into consideration
current healthcare laws within the U.S. and the nurse’s role within this continuously
changing environment; the manner in which quality measures and pay for performance
affect patient outcomes. Furthermore, the emerging trends in the healthcare system,
professional nursing leadership, and management roles will be discussed.
The Emerging Health Care Laws and their Effects on Nursing Practice
One of the most crucial healthcare legislat ions that has been enacted in the United
States since the inception of Medicare and Medicaid in 1965 is the Affordable Care
Act (Obama, 2016). The ACA was enacted in 2010. Issues relat ing to affordability,
ease of access, and the care quality within the United States healthcare system were
some of the driving factors that formed the list of many t ime spanning challenges
that compiled the init iat ion of this legislat ion. Between 2010 to 2015 there was a
decrease in the number of uninsured cit izens in the U.S. by forty three percent as an
effect of the Affordable Care Act.
The payment systems in healthcare are undergoing some changes and the access to
care has also improved (Obama, 2016). The ACA promotes preventive healthcare
models that put emphasis on quality care, primary care, and the funding of community
health init iat ives (Lathrop and Hodnicki, 2014). Millions of previously uninsured cit izens
are also provided insurance coverage and also some healthcare areas that need
reforms so as to meet the needs of patients’ improved healthcare outcomes are
highly focused by the act. The act has an effect on nursing practice in several ways.
The first effect is that the act creates a high demand for healthcare professionals
that are sufficiently trained to provide healthcare services that are up to the acts’
standards. The second effect is that Advanced Practice Registered Nurses (APRNs)
who hold the Doctor of Nursing Practice (DNP) are required to be prepared so that
they can meet the increased needs through the provision of leadership skills in
community health centers. These professionals are also held accountable for direct ing
and advocating for future init iates as well as ser.
DQ 3-2Integrated health care delivery systems (IDS) was develope.docxelinoraudley582231
DQ 3-2
Integrated health care delivery systems (IDS) was developed to initiate excellence health care access and quality of care to entire populations and community by collaborating and coordinating diverse healthcare professionals. Main driving force of IDS is patient centered care by using resources such as collaborating care from physicians and allied health care professionals to construct continuum of care, to deliver care in the most cost-effective way, utilize trained and competent providers by utilizing evidenced -based practice and combine innovation such as EHR (Electronic Health Records) system and team work to produce improved healthcare system.
Excellence in care is attainable by incorporating allied healthcare professional, as high quality care is possible when coordination is unified and covers all areas of responsibilities. For an example-combining resources and coordination of care by involving physicians, dietitian, physical therapy or occupational therapy to work with patient diagnosed with obesity by promoting teamwork approach and ultimately delivering endurance in care and utilizing various resources.
Barriers to IDS can be a huge block in delivering quality care. Among many one limitation is physicians not participating in integrated healthcare system, which disconnect physicians from team based approached by deterring continuous quality improvement (essentialhospitals.org, n.d). This is because, system such as EHR or new innovative quality assurance programs are time consuming and overwhelming, thus decline in physicians support in IDS programs. By implementing user friendly system approach, enforcing focused based care and accepting the necessity of evidenced based practice can improve these barriers. Hence, increasing clinical expertise to produce better service and quality of care in integrated delivery system.
Essentialhospitls.org (n.d). Retrieved from: http://essentialhospitals.org/wp-content/uploads/2013/12/Integrated-Health-Care-Literature-Review-Webpost-8-22-13-CB.pdf
Dq 3-1
1.
In the US, there is not one type of health care system but rather a subset of systems, some of them catering to specific populations. These subsystems include managed care, military, and vulnerable populations. Managed care is a health care delivery system that seeks to achieve efficiency by integrating the basic functions of health care delivery, employs mechanisms to control utilization of medical services, and determines the price at which the services are purchased and how much the providers get paid, military health care system is available free of charge to active duty military personnel and covers preventative and treatment services that are provided by salaried health care personnel and this system combines public health with medical services, and vulnerable population subsystem offers comprehensive medical and enabling services targeted to the needs of vulnerable populations and government health insurance programs provide.
Hospitalist programs are increasingly used by hospitals to manage the shift to value-based care and reduce costs. The use of hospitalists has grown significantly, with approximately 75% of hospitals now utilizing hospitalists. Hospitalist programs can improve outcomes, drive cost efficiencies, and increase reimbursements by reducing lengths of stay and readmission rates. While hospitalists provide benefits, there is debate around their impact on overall patient health and outcomes. As value-based payments increase, demand for hospitalists is expected to continue growing as they help hospitals achieve quality metrics and financial targets.
Regulatory reforms and advances in technology are enabling a shift from reactive, provider-centric healthcare to proactive, population-based healthcare management. This involves collecting and analyzing patient data from multiple sources to better understand patient needs, identify patterns, and implement preventative programs and automated interventions. The goal is to improve health outcomes and reduce costs by keeping populations healthy and minimizing expensive medical procedures. Healthcare organizations must adopt new data-driven care models, tools, and workflows to effectively manage population health.
Population Health Management White Paper, Spring 2015Edward Pierce
Population health management (PHM) aims to improve health outcomes for groups of individuals through coordinated care and patient engagement. Key components of PHM include leadership from primary care physicians to develop customized care plans for each patient. Data analysis is used to identify at-risk patients and care gaps, while automation and technology help disseminate information to patients. Referral networks and payment structures incentivize physicians to focus on outcomes over volume. Hospitals are developing PHM strategies starting with their own employees to coordinate benefits, replicate the model, and expand it community-wide to improve affordability.
This document discusses the patient-centered medical home (PCMH) model and its benefits. It provides examples of organizations that have implemented PCMH initiatives to improve care coordination, access, costs and outcomes. Key points include:
- PCMH aims to strengthen primary care through care coordination, enhanced access, quality improvement and payment reform.
- Studies show PCMH can reduce costs by decreasing ER visits and hospital days while improving outcomes.
- Several large employers, the Department of Defense, and state governments have adopted PCMH models for the populations they insure.
- Successful PCMH models integrate primary care, specialists, hospitals, and community resources through use of health IT, data sharing and care
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